Provider Demographics
NPI:1265464499
Name:BLAKELY, LAURA JOHNETTA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JOHNETTA
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440100
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0100
Mailing Address - Country:US
Mailing Address - Phone:615-871-9996
Mailing Address - Fax:615-871-9661
Practice Address - Street 1:5653 FRIST BLVD
Practice Address - Street 2:SUITE 434
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2062
Practice Address - Country:US
Practice Address - Phone:615-871-9996
Practice Address - Fax:615-871-9661
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38475207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7820270OtherAETNA
AR99620OtherBCBS AR
TN4087020OtherBCBS TN